Health Information Management Exam Practice Tests
Course Introduction
Health Information Management explores the systems and processes used to collect, store, retrieve, and protect health information in various healthcare settings. The course covers fundamental concepts such as medical coding, electronic health records (EHR), data privacy and security, legal and ethical considerations, and the integration of information technology in health care. Emphasis is placed on developing skills for managing patient records, ensuring compliance with regulatory requirements, and using data analytics to support decision-making and improve patient outcomes. Students will gain an understanding of the vital role that accurate and secure health information plays in delivering quality healthcare services.
Recommended Textbook
ICD 10 CM PCS Coding Theory and Practice 2017 Edition 1st Edition by Karla R. Lovaasen
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26 Chapters
1611 Verified Questions
1611 Flashcards
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Chapter 1: The Rationale for and History of Coding
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47 Verified Questions
47 Flashcards
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Sample Questions
Q1) Medical coding
A)Has more than 100,000 members and was started in 1981
B)Translating diagnoses and procedures into special alphanumeric characters for the purposes of statistically capturing data
C)Grouping like items together for easy storage and retrieval
D)To maintain credentials,coders must earn these
E)Published by the College of American Pathologists,the most up-to-date system of nomenclature
F)The current coding classification system in use in the United States
Answer: B
Q2) HIPAA stands for __________ of 1996.
Answer: Health Insurance Portability and Accountability Act
Q3) RHIT
A)American Academy of Professional Coders
B)Certified Coding Specialist
C)American Hospital Association
D)National Center for Health Statistics
E)Registered Health Information Technician
Answer: E
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Page 3
Chapter 2: The Health Record As the Foundation of Coding
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42 Verified Questions
42 Flashcards
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Sample Questions
Q1) Chronic conditions include all of the following EXCEPT ____.
A)hypertension
B)congestive heart failure
C)diverticulitis
D)emphysema
E)all of the above are correct
Answer: C
Q2) Abnormal findings (laboratory,X-ray,pathologic,and other diagnostic results)are always coded and reported when they are found.
A)True
B)False
Answer: False
Q3) What is the definition of subjective complaint as it applies to a patient coming to a healthcare facility?
Answer: The problem stated in the patient's own words
Q4) What does MRI stand for?
Answer: Magnetic resonance imaging
Q5) What does AHQA stand for?
Answer: American Health Quality Association
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Chapter 3: ICD-10-Cm Format and Conventions
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39 Verified Questions
39 Flashcards
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Sample Questions
Q1) The code "L05.0 pilonidal cyst and sinus with abscess" represents a ____.
A)chapter
B)section
C)category
D)subcategory
Answer: D
Q2) "____" is a reference that instructs coders to look up another term to locate a code for a particular condition.
A)See category
B)And
C)See condition
D)Eponym
Answer: C
Q3) In ICD-10-CM the final character of a code assignment can never be a letter.
A)True
B)False
Answer: False
Q4) __________,a form of punctuation,are used in the index to identify manifestation codes in the Alphabetic Index.
Answer: Brackets
Page 5
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Chapter 4: Basic Steps of Coding
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35 Verified Questions
35 Flashcards
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Sample Questions
Q1) Modifiers of the main term that have an effect on the appropriate code choice
A)Tabular List
B)See also
C)Subterms
D)Discharge summary
E)Coding Clinic
F)ER
G)Differential diagnosis
H)Chief complaint
I)The first basic step in coding the principal diagnosis
J)Nonessential modifiers
Q2) Exceptions to the general rule that main terms usually identify disease conditions are Z codes.
A)True
B)False
Q3) What is the main term in "rheumatoid arthritis"?
Q4) What is the subterm in "infantile eczema"?
Q5) Once a code has been selected from the Alphabetic Index to Diseases,what is the next step?
Page 6
Q6) What is the main term in "calculus of the ureter"?
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Chapter 5: General Coding Guidelines for Diagnosis
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27 Verified Questions
27 Flashcards
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Sample Questions
Q1) What are the diagnosis code(s)for acute and chronic pancreatitis?
Q2) If a patient is admitted for a complication due to a surgical procedure,the reason for the surgical procedure is the principal diagnosis.
A)True
B)False
Q3) In the inpatient setting,it is not acceptable to code diagnoses that have not yet been confirmed and are questionable or suspected.
A)True
B)False
Q4) A patient is admitted to the hospital with Crohn's disease,hypertension,and rheumatoid arthritis for bowel resection.In the OR before incision,the patient develops tachycardia,and the procedure is canceled.What is the principal diagnosis?
Q5) What is the diagnosis code(s)for acute and chronic cholecystitis?
Q6) When the patient is admitted for a complication due to a surgical procedure,the complication is the principal diagnosis.
A)True
B)False
Q7) What is the diagnosis code(s)for acute and chronic bronchitis?
Page 7
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Chapter 6: Introduction to ICD-10-PCS
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127 Verified Questions
127 Flashcards
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Sample Questions
Q1) The fourth character of an ICD-10-PCS code represents a(an)____.
A)body part
B)approach
C)section
D)device
Q2) ____________________ is a minimally invasive technique that uses robotic arms to manipulate the surgical equipment and tools.
Q3) Visually and/or manually exploring a body part is called ____.
A)creation
B)fusion
C)inspection
D)map
Q4) Which character identifies the body part in an ICD-10-PCS code?
Q5) Modifying the natural anatomic structure of a body part without affecting the function of the body part is called ____.
A)alteration
B)fusion
C)creation
D)repair
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Chapter 7: General Coding Guidelines for Other Medical-
and Surgical-Related Procedures and Ancillary Procedures
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109 Verified Questions
109 Flashcards
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Sample Questions
Q1) Planar bone scan,entire musculoskeletal using Tc-99m
Q2) Radionuclide is the second character in the nuclear medicine section.
A)True
B)False
Q3) In ICD-10-PCS,abortion is defined as the spontaneous termination of a pregnancy. A)True
B)False
Q4) Abortion induced with laminaria
Q5) Medication management for mental health issues
Q6) The first character value for a mental health procedure is G.
A)True
B)False
Q7) Acupuncture can be coded in the other procedures section of ICD-10-PCS.
A)True B)False
Q8) The term products of conception refers to all physical components of a pregnancy,including the fetus,amnion,umbilical cord,and placenta.
A)True
B)False Page 9
Q9) Hypnosis
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Page 10
Chapter 8: Coding Medical and Surgical Procedures
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66 Verified Questions
66 Flashcards
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Sample Questions
Q1) An obstetric procedure is any procedure performed on a pregnant woman.
A)True
B)False
Q2) Open CABG bypass of two coronary arteries using the saphenous vein (aorta to coronary artery)and one artery with the left internal mammary artery,which was used as a pedicle graft to coronary artery.The left greater saphenous vein was harvested via percutaneous endoscopic approach.Cardiopulmonary bypass machine was utilized during the procedure.
Q3) Percutaneous repositioning of dislocated atrial pacemaker lead
Q4) Bilateral fallopian tubal occlusion with Falope ring device,laparoscopic approach
Q5) When a patient shows up to have a procedure performed,but the procedure is canceled for whatever reason,the principal diagnosis would be
Q6) An additional code should always be assigned for closure of the surgical incision.
A)True
B)False
Q7) Closed reduction of right radial fracture
Q8) Transurethral endoscopic laser ablation of prostate
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Chapter 9: Symptoms,
signs, and
Abnormal
Clinical and Laboratory Findings Not Elsewhere Classified, and Z Codes
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57 Verified Questions
57 Flashcards
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Sample Questions
Q1) Principal diagnosis is documented as right upper quadrant abdominal pain due to cholecystitis versus peptic ulcer disease: __________
Q2) Counseling on the initiation of contraceptive foam use: __________
Q3) Where are Z codes located in the Tabular List of the coding book?
Q4) A 6-month-old infant was admitted with a febrile seizure.The patient had a temperature of 103°F.The patient was discharged to the care of the parents on the following day.
Final Diagnosis: Febrile seizure.
A)R56.01
B)R56.9
C)R56.00
D)R56.00.
Q5) Gas pain: __________
Q6) Impending stroke with dizziness and facial weakness: __________
Q7) Retained metal fragment: __________
Q8) ICD-10-CM provides codes to deal with encounters for circumstances other than a disease or injury.
A)True
B)False Page 12
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Chapter 10: Certain Infectious and Parasitic Diseases
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62 Verified Questions
62 Flashcards
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Sample Questions
Q1) A patient is admitted to the hospital with severe diarrhea.Upon examination the patient is found to be severely dehydrated.She is given IV fluids to correct the hydration.In the assessment the physician suspects gastroenteritis.After stool cultures,it is determined that the patient has Clostridium difficile colitis.
A)K52.9,E86.0,R19.7
B)A04.7,E86.0
C)A04.7,R19.7
D)K52.9,R19.7
Q2) Category A00-A09 contains codes for ____________________.
Q3) How many stages of syphilis are there?
A)One
B)Two
C)Three
D)Four
Q4) Jock itch is coded to ____.
A)B35.9
B)B35.8
C)B35.6
D)B35.4
Q5) Assign the code(s)for diaper rash due to candidiasis.
Page 14
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Chapter 11: Neoplasms
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69 Verified Questions
69 Flashcards
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Sample Questions
Q1) All of the following are factors influencing which kind of biopsy will be performed for a patient EXCEPT the ____.
A)weight of the patient
B)location of the mass
C)age of the patient
D)available technology
Q2) What drug could be given to treat anemia due to malignancy?
A)Nolvadex
B)Neupogen
C)Neulasta
D)Epogen
Q3) Neoplasms can affect ONLY certain specific body systems.
A)True
B)False
Q4) What does it mean when a tumor is benign?
Q5) An example of a carcinoma malignancy is a malignant ____.
A)tumor in the bone marrow
B)stomach tumor
C)tumor in the muscle
D)tumor of the breast
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Chapter 12: Diseases of the Blood and Blood-Forming
Organs and Certain Disorders Involving the Immune
Mechanism
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71 Verified Questions
71 Flashcards
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Sample Questions
Q1) A patient's own blood sometimes donated before an elective surgery in case (s)he needs a transfusion
A)Apheresis
B)Blood
C)Autologous transfusion
D)5000 to 10,000/mm³
E)Hemoglobin (HGB)
F)Purpura
G)Idiopathic
H)Hematocrit (Hct)
I)Bone marrow biopsy
J)WBC
K)Secondary thrombocytopenia
Q2) Familial erythrocytosis: __________
Q3) Scorbutic anemia: __________
Q4) Vegan's anemia: __________
Q5) Childhood anemia: __________
Q6) What are two reasons for iron deficiency? Page 16
Coagulopathy due to chronic liver disease: __________
Q8) Postoperative anemia: __________
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Page 17
Chapter 13: Endocrine, nutritional, and Metabolic Diseases
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68 Verified Questions
68 Flashcards
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Sample Questions
Q1) All of the following are possible signs of malnutrition EXCEPT ____.
A)loss of energy
B)diarrhea
C)rapid hair growth
D)skin lesion
E)none of the above are correct
Q2) An adult patient was seen in the clinic for dietary counseling for dysmetabolic syndrome X.The patient is obese with a BMI of 35 and has hypertriglyceridemia and hypertension.
A)Z71.3,E88.81,E66.9,Z68.35,E78.1,I10
B)Z71.9,E88.81,E66.3,Z68.35,E78.1,I10
C)E88.81,E66.9,Z68.35,E78.1,I10,Z71.3
D)E66.9,E88.81,Z68.35,E78.1,I10,Z71.3
Q3) In ICD-10-CM,if the diabetes is due to an adverse effect of a drug,there is an Instructional note to assign a T36-T50 code as an additional or secondary code.
A)True
B)False
Q4) Diabetes mellitus with hypoglycemic coma: __________
Q5) Graves disease with thyrotoxic storm: __________
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Chapter 14: Mental, behavioral, and Neuro developmental Disorders
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72 Verified Questions
72 Flashcards
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Sample Questions
Q1) Name some symptoms/signs that characterize ADD or ADHD.
Q2) Which of the following can cause intellectual disability in a child during the mother's pregnancy?
A)Malnutrition
B)Mother's use of alcohol or drugs
C)Environmental toxins such as lead or mercury
D)All of the above
Q3) A disorder of the brain
A)Sexual problems
B)PTSD-posttraumatic stress disorder
C)Phobias
D)Panic disorder
E)Generalized anxiety disorder
F)Mood disorders
G)Schizophrenia
Q4) Which of the following is NOT one of the five types of schizophrenia?
A)Undifferentiated
B)Paranoid
C)Manoliphic
D)Catatonic
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Chapter 15: Diseases of the Nervous System, diseases of
the Eye and Adnexa, and Diseases of the Ear and Mastoid Process
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55 Verified Questions
55 Flashcards
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Sample Questions
Q1) Patient came to the ER after falling off her horse at the county fair rodeo.X-rays reveal two fractured ribs on the left.Patient is admitted for acute pain control.
A)S22.42xA,G89.11,V80.010A,Y92.39,Y93.52
B)G89.18,S22.42xA,V80.010A,Y92.39,Y93.52
C)G89.11,S22.42xA,V80.010A,Y92.39,Y93.52
D)S22.42xA,R52,V80.010A,Y92.39,Y93.52
Q2) What drug could be given to treat Alzheimer's?
A)Sinemet
B)Depakote
C)Aricept
D)Dilantin
Q3) A college student is admitted with fever,headache,and a stiff neck.Lumbar puncture is performed in the ER,and lab results reveal pneumococcal meningitis.The patient is given IV fluids for volume depletion and IV antibiotics to treat meningitis.
A)G00.1,E86.9,009U3ZZ
B)R50.9,R51,M43.6,009U3ZX
C)R50.9,R51,M43.6,G00.1,009U3ZZ
D)G00.1,E86.9,009U3ZX
Page 20
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Chapter 16: Diseases of the Circulatory System
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65 Verified Questions
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Sample Questions
Q1) A patient is admitted with facial droop,right-sided hemiparesis,and nystagmus.Testing reveals occlusion of the left carotid artery with cerebral infarct.The patient has uncontrolled hypertension and atrial fibrillation,which is treated with Coumadin.Before discharge the patient's nystagmus and facial droop have resolved.The patient is discharged to rehab for continued therapy for right-sided hemiparesis.
A)I63.232,G81.90,I10,I48.91,Z79.01
B)I63.232,G81.91,H55.00,R29.810,I10,I48.91,Z79.01
C)G81.90,I63.232,I10,I48.91,Z79.01
D)I65.22,G81.90,H55.00,I10,I48.91,Z79.01
Q2) Deep vein thrombosis (DVT)is a blood clot that forms deep in a vein,usually in the leg or hip.
A)True
B)False
Q3) The two main types of heart failure are systolic and diastolic.
A)True
B)False
Q4) Inflamed stasis ulcers of the left leg (calf)with fat layer exposed in a patient with varicose veins: __________
Q5) ____________________ is the sudden loss of heart function.
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Chapter 17: Diseases of the Respiratory System
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73 Verified Questions
73 Flashcards
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Sample Questions
Q1) Cork handlers' disease: __________
Q2) A patient is admitted from a nursing home with cough and fever.The patient has a history of dysphagia and hemiparesis due to previous cerebral infarction.Sputum cultures reveal Pseudomonas.
Discharge Diagnosis: Pneumonia due to aspiration and Pseudomonas bacteria.
A)J69.0,J15.1,I69.391,I69.352
B)J15.0,J69.0,I69.391,I69.359
C)J69.0,J15.1,I69.391,R13.10,I69.359
D)J18.9,J15.1,I69.391,R13.10,I69.359
Q3) Acute bronchiolitis due to RSV: __________
Q4) Patient was admitted with cough and fever.Patient is HIV positive.Physician documents that the BAL (right main bronchus)confirmed Pneumocystis carinii pneumonia.
A)B20,J16.8,3E1F88X
B)B59,Z21,0B9K8ZX
C)B20,B59,0B938ZX
D)B59,B20,0B9B8ZX
Q5) Laryngeal spasm: __________
Q6) Eosinophilic asthma: __________
Q7) Idiopathic pulmonary fibrosis: __________
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Chapter 18: Diseases of the Digestive System
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60 Verified Questions
60 Flashcards
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Sample Questions
Q1) Code ____ is coded for personal history of malignant neoplasm of the GI tract,unspecified.
A)Z85.00
B)Z80.9
C)Z80.0
D)Z85.09
Q2) What is an ulcer (such as of the stomach or intestine)?
Q3) Name one purpose of the small intestine.
Q4) A patient is admitted with recurrent right inguinal hernia.The hernia cannot be reduced,and the patient is taken to the OR for an open repair of indirect hernia with mesh.The patient spikes a fever on day 2,and workup reveals a UTI.What codes are applicable?
Q5) Patient with vomiting and abdominal pain is admitted to the hospital.After workup,it is determined that the patient has appendicitis.The patient is taken to the OR for a laparoscopic appendectomy.The pathology report shows that the patient suffered from acute appendicitis with an abscess.
A)K35.3,R10.9,0DYJ0ZZ
B)K35.3,0DTJ4ZZ
C)R10.9,K35.1,0DTJ4ZZ
D)K35.9,R10.9,0DTJ0ZZ
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Chapter 19: Diseases of the Skin and Subcutaneous Tissue
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57 Verified Questions
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Sample Questions
Q1) A type of dermatitis characterized by a type of rash found in body folds
A)Decubitus ulcer
B)Skin ulcers
C)Cellulitis
D)Stasis ulcer
E)Stasis dermatitis
F)Intertriginous dermatitis
G)Gangrene
H)Hives
I)Dermatitis
Q2) Another name for furuncle is a(n)____________________.
Q3) Diseases of the skin and subcutaneous tissues are coded ____.
A)G00-G99
B)M00-M99
C)L00-L99
D)C00-D49
Q4) The skin is composed of ____________________ layers.
Q5) What are the three types of glands located in the skin?
Q6) What is an abscess of the skin?
Q7) Exfoliative dermatitis: __________
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Chapter 20: Diseases of the Musculoskeletal System and Connective Tissue
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63 Verified Questions
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Sample Questions
Q1) The patient was admitted from the ER for chest pain to rule out MI.The patient also had some difficulty breathing and pain when taking a deep breath.The patient does have a family history of ischemic heart disease and is positive for the following cardiac risk factors: male,older than age 65,hypertension,smoker,and overweight.After evaluation and monitoring,an MI was ruled out.Cardiology thought the most likely cause for his chest pain was costochondritis.
Final Diagnoses: Chest pain due to costochondritis. Hypertension.
Smoker,current nicotine dependence (cigarettes). Overweight.
Family history of ischemic heart disease.
A)M94.20,I10,E66.2,F17.211,Z82.49
B)M94.0,I11.9,F17.229,E66.3,Z82.41
C)M94.0,I10,F17.210,E66.3,Z82.49
D)M94.1,I10,Z72.0,E66.8,Z82.49
Q2) Calcification of lumbar disc: __________
Q3) Internal derangement of left knee: __________
Q4) What is the purpose of the musculoskeletal system?
Q5) Tennis elbow (right): __________
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Chapter 21: Diseases of the Genitourinary System
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Sample Questions
Q1) Small kidneys,bilaterally: __________
Q2) ____________________ is the presence of blood in the urine.
Q3) Cancer of the prostate with radical prostatectomy (including bilateral seminal vesicles)with bilateral regional pelvic lymphadenectomy (diagnostic sampling).
A)D29.1,0VT00ZZ,0VT30ZZ,07BC0ZZ
B)D29.8,0VT04ZZ,0VTC4ZZ,07BC4ZZ
C)C63.7,0VT04ZZ,0VTC4ZZ,07BC4ZX
D)C61,0VT00ZZ,0VT30ZZ,07BC0ZX
Q4) ____________________ is a chronic condition in which endometrial material,the tissue that lines the inside of the uterus,grows outside the uterus and attaches to other organs in the pelvic cavity.
Q5) Ulceration of the vulva: __________
Q6) A patient is admitted to the hospital for fluid overload due to noncompliance with attending renal dialysis sessions.Patient has stage 5 CKD.Multiple sessions of hemodialysis are performed.
A)E87.70,N18.6,Z91.15,5A1D60Z
B)E87.70,N18.6,Z91.15,5A1D00Z
C)N18.6,E87.79,Z99.2,5A1D00Z
D)E87.79,N18.5,Z99.2,5A1D60Z
Page 26
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Chapter 22: Pregnancy, childbirth, and the Puerperium
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Sample Questions
Q1) In ICD-10-CM the diagnosis used for an elective abortion comes from the pregnancy chapter.
A)True
B)False
Q2) Gestational edema,second trimester antepartum (25 weeks): __________
Q3) The patient is admitted in labor at 38 weeks.She labors for 24 hours,when it is noted that the baby is in fetal distress.The patient is taken to the OR for an emergency C-section (LTCS).She delivers a healthy baby.
A)O77.9,Z3A.38,Z37.0,10D00Z1
B)O77.8,Z3A.38,Z38.003
C)O77.8,Z3A.38,Z37.0,10D00Z1
D)O77.9,Z3A.38,Z38.00,10D00Z0
Q4) Complications of pregnancy,childbirth,and the puerperium are coded ____.
A)M00-M99
B)L00-L99
C)O00-O9A
D)Q00-Q99
Q5) What does it mean when a pregnant woman is called primigravida?
Q6) What is tested for in a female's urine sample to confirm that she is pregnant?
Q7) What happens in a molar pregnancy?
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Chapter
Period and Congenital Malformations, deformations, and
Chromosomal Abnormalities
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Sample Questions
Q1) Occurs in the fifth week of fetal development and is characterized by a small pouch on the wall of the small bowel containing ectopic tissue
A)Klinefelter's syndrome
B)Spina bifida
C)Meckel's diverticulum
D)Marfan syndrome
E)Tetralogy of Fallot
F)Down syndrome
Q2) Which of the following makes a condition clinically significant?
A)The condition requires a clinical evaluation.
B)The condition requires therapeutic treatment.
C)The condition requires an extended hospital stay.
D)All of the above are correct.
Q3) A code from category A41,septicemia,should not be used on a(n)____ record.
A)newborn
B)child
C)teenager
D)adult
Q4) What is a congenital anomaly?
Q5) Imperforate hymen: __________
28
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Chapter 24: Injuries and Certain Other Consequences of
External Cases and External Causes of Morbidity
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Sample Questions
Q1) All of the following are symptoms of fat embolism syndrome EXCEPT ____.
A)tachycardia
B)elevated temperature
C)decreased temperature
D)hypoxemia
Q2) Name some diagnostic tools used to diagnose injuries.
Q3) When the bone is somewhat bent and partially broken;usually occurs in children
A)Crush injury
B)Fissured fracture
C)Comminuted fracture
D)Greenstick fracture
E)External skeletal fixation
F)Contusion
Q4) A break in a bone is called a(n)____________________.
Q5) A(n)____________________ fracture causes injury to the surrounding tissues.
Q6) Fractured coccyx,initial encounter: __________
Q7) ICD-10-CM guidelines state that if the intent of an injury is unknown or unspecified,code the intent as accidental.
A)True
B)False Page 30
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Chapter 25: Burns, Adverse Effects, and Poisonings
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Sample Questions
Q1) Through the acute and recovery stages of a burn victim,which of the following will most likely assist the victim?
A)Plastic surgeons
B)Anesthesiologists
C)Physical therapists
D)All of the above
Q2) Deep necrosis of underlying tissues
A)First-degree
B)Second-degree
C)Third-degree
D)Fourth-degree
Q3) First- and second-degree burn of face due to gas flame from stove in kitchen at patient's house while cooking: __________
Q4) Z codes are never assigned in relation to injuries,burns,adverse effects,and poisoning.
A)True
B)False
Q5) A side effect or reaction to a drug that has been taken properly is called a(n)____________.
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Chapter 26: Complications of Surgical and Medical Care
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Sample Questions
Q1) NSTEMI following laparoscopic appendectomy for acute appendicitis.Physician documents that the NSTEMI was due to the procedure: __________
Q2) A patient comes to the hospital with chronic cholecystitis,and a laparoscopic cholecystectomy is performed.The patient's bowel function was slow to return,and on day 3 the patient developed a postoperative obstructionthat was slow to resolve.__________
Q3) Occurs when the fracture fragments have united but are not properly aligned.
A)Malunion
B)Nonunion
C)Neuroma
D)Extravasation
E)Contracture
F)Necrosis
Q4) A patient comes to the hospital with acute appendicitis and is taken to the OR for an open appendectomy.During the course of the surgery,the liver is accidentally lacerated and repaired with sutures.The patient recovers without any ill effects.__________
Q5) Leaking silicone breast implant,initial visit: __________
Q6) Patient has subclavian vein thrombosis due to PICC: __________
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